Effectiveness of primary percutaneous coronary intervention compared with that of thrombolytic therapy in elderly patients with acute myocardial infarction

Background

Few data exist from a community-based perspective on the relative effectiveness of primary percutaneous coronary intervention (PCI) as compared with thrombolytic therapy (TT) in elderly patients with ST-elevation myocardial infarction (STEMI), particularly in the current era of coronary stents and newer antithrombotic agents.

Methods

We evaluated data from patients, aged ≥70 years, with STEMI who were enrolled in the Global Registry of Acute Coronary Events study between April 1999, and September 2002.

Results

Of the 2975 elderly patients eligible for reperfusion therapy, 365 (12.7%) underwent primary PCI and 769 (26.7%) received TT. The median delay from hospital arrival to therapy was 105 minutes for primary PCI and 40 minutes for TT. Inhospital complications for primary PCI versus TT included mortality (13.5% vs 14.8%), reinfarction (1.1% vs 5.7%), composite of death or reinfarction (14.3% vs 18.7%), cardiogenic shock (11.3% vs 11.6%), major bleeding (8.6% vs 5.9%), and stroke (1.1% vs 2.8%). After adjustment for baseline differences and propensity score, patients receiving primary PCI showed a lower rate of reinfarction (odds ratio [OR], 0.15; 95% CI, 0.05-0.44) and mortality (OR, 0.62; 95% CI, 0.39-0.96) and the composite of reinfarction or death (OR, 0.53; 95% CI, 0.35-0.79), with no difference in other outcome measures.

Conclusion

Our data suggest that, compared with TT, primary PCI is associated with a decrease in reinfarction and mortality, with no change in other outcome measures, in elderly patients with STEMI. These findings from an observational registry require further confirmation in future randomized clinical trial assessing the optimal reperfusion strategy in the elderly cohort with STEMI.     

Burn size estimation in children: Still a problem

Background: Accurate determination of burn size and depth forms an integral part of the initial assessment of any burn injury. Errors might lead to inaccurate fluid resuscitation and inappropriate transfer of patients to specialized burns units (BUs). Although recent data suggest some improvement in the estimation of burn injury in adults, this has not been shown in children. Methods: A retrospective review of children with burn injuries referred to the BU of our institution was performed. Data were collected from all patients presenting to the BU during the calendar year 2009. The total body surface area burned (TBSA‐B) estimated by the referring centre was compared with the actual TBSA determined measured on arrival at the BU. Results: Of the 71 paediatric patients referred during the study period, 10 did not have any TBSA‐B estimation documented by the referring hospital. Inaccurate estimation of burn area was noted in 48 out of 61 patients (79%). Burn size was more likely to be overestimated than underestimated by a ratio of 2.2 to 1, especially in burns >10% TBSA‐B (P= 0.002). Conclusions: Inaccurate estimation of burn size remains a problem in children. The persistent miscalculation of burn size might be a result of the various methods employed in assessing burn area, the inclusion of simple erythema and inadequate training or exposure of first responders. Accurate assessment of TBSA‐B and burn depth in children remains elusive and would appear to require additional training and education.     

Obstetric complications in Marfan syndrome

OBJECTIVE: To investigate the obstetric maternal and neonatal outcome of pregnancy in women with Marfan syndrome. METHODS: Retrospective observational multi-center study based on congenital heart disease registry. RESULTS: Sixty-three of the 122 enrolled women with Marfan syndrome had been pregnant 142 times (including 111 pregnancies>20 weeks, 28 (20%) miscarriages and 3 elective abortions). In 40% of all completed pregnancies an obstetric and/ or neonatal complication occurred. The most important complications were an increased percentage of premature deliveries (n=17, 15%) mainly due to preterm premature rupture of membranes and cervical incompetence and a markedly increased combined fetal and neonatal mortality of 7.1%. An obstetric and/or neonatal complication occurred in a similar proportion of pregnancies in women with a diagnosis of Marfan syndrome before pregnancy versus women with a diagnosis of Marfan syndrome after pregnancy (39% vs. 41%, p=0.85, respectively). CONCLUSION: In addition to cardiovascular complications, pregnancy in women with Marfan syndrome is associated with a high rate of premature deliveries, preterm premature rupture of membranes and increased mortality in the offspring.     

Incidence and predictors of all and preventable adverse drug reactions in frail elderly persons after hospital stay

BACKGROUND: Adverse drug reactions (ADR) negatively impact life quality and are sometimes fatal. This study examines the incidence and predictors of all and preventable ADRs in frail elderly persons after hospital discharge, a highly vulnerable but rarely studied population. METHODS: The design was a prospective cohort study involving 808 frail elderly persons who were discharged from 11 Veteran Affairs hospitals to outpatient care. The main outcome measure was number of ADRs per patient as determined by blinded geriatrician and geropharmacist pairs using Naranjo's ADR algorithm. For all ADRs (possible, probable, or definite), preventability was assessed. Discordances were resolved by consensus conferences. RESULTS: Overall, 33% of patients had one or more ADRs for a rate of 1.92 per 1000 person-days of follow-up. The rate for preventable ADRs was 0.71 per 1000 person-days of follow-up. Independent risk factors for all ADRs were number of medications (adjusted [Adj.] hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.05-1.10 per medication), use of warfarin (Adj. HR, 1.51; 95% CI, 1.22-1.87), and (marginally) the use of benzodiazepines (Adj. HR, 1.23; 95% CI, 0.95-1.58). Counterintuitively, use of sedatives and/or hypnotics was inversely related to ADR risk (Adj. HR, 0.14; 95% CI, 0.04-0.57). Similar trends were seen for number of medications and warfarin use as predictors of preventable ADRs. CONCLUSIONS: ADRs are very common in frail elderly persons after hospital stay, and polypharmacy and warfarin use consistently increase the risk of ADRs.     

A dithiocarbamate analogue decreases intraislet cell infiltration and the incidence of diabetes mellitus in the genetic diabetes-prone BB rat

SUMMARY: Dithiocarbamates are a class of agents that have interesting biologic properties including the ability to limit the production and/or action of nitric oxide (NO). These agents are also potential immunosuppressant agents. Since immunosuppressant agents have been examined for remission of disease in clinical trials, we wanted to examine whether a dithiocarbamate analogue, NOX-200, might inhibit diabetogenesis in the genetic diabetes-prone BB rat model. Immunohistochemical analysis revealed inducible NO synthase (iNOS) gene expression in pancreatic islets of both normoglycemic and hyperglycemic diabetes-prone BB rats but not in diabetes-prone BB rats at the early age of 30 days or in diabetes-resistant BB rats. A qualitative decrease in immunostaining for iNOS was also observed in the pancreata of drug-treated animals. Long-term treatment with NOX-200, used alone or in combination with low-dose cyclosporine (CsA), significantly reduced the incidence of diabetes mellitus. In the subset of animals that became diabetic, NOX-200 did not alter either the time to onset of hyperglycemia or the level of hyperglycemia, insulinopenia, or lymphocytic cell infiltration into the pancreas. In contrast, in animals that did not develop hyperglycemia, treatment with NOX-200 decreased inflammatory cell infiltration into the pancreas equipotent to that seen using CsA. These studies demonstrate the potential therapeutic efficacy of dithiocarbamates to oppose the development of autoimmune insulin-dependent diabetes mellitus by limiting inflammatory cell activation/infiltration.     

Outcomes of patients with acute coronary syndromes and prior percutaneous coronary intervention: a pooled analysis of three randomized clinical trials.

AIMS: We sought to characterize the outcomes of patients with a prior percutaneous coronary intervention (PCI) who presented with a non-ST-segment elevation acute coronary syndrome (ACS). METHODS AND RESULTS: We analysed the 30 and 180 day outcomes of 3012 patients with prior PCI and 21 154 patients without prior PCI enrolled in three randomized ACS trials (GUSTO IIb, PURSUIT, and PARAGON-B). The median (25th, 75th percentile) interval between the prior PCI and randomization was 647 (123, 1585) days. Patients with prior PCI had significantly more adverse baseline clinical characteristics, left ventricular dysfunction, and multi-vessel coronary artery disease. After adjusting for baseline characteristics and treatment, we found that patients with prior PCI had a significantly lower mortality rate at 30 days [hazard ratio (HR), 0.60; 95% confidence interval (CI), 0.45-0.80; P=0.0006] and 180 days (HR, 0.81; 95% CI, 0.66-0.98; P=0.029). However, no difference was observed in the composite of death or myocardial infarction (MI) at 30 days (HR, 0.95; 95% CI, 0.83-1.08; P=0.42) or 180 days (HR, 1.01; 95% CI, 0.90-1.13; P=0.90). Patients with prior PCI had a higher rate of MI at 180 days (13.3 vs. 12.0%; P=0.045). Prior-PCI patients had lower incidences of in-hospital cardiogenic shock, congestive heart failure (CHF), and atrial fibrillation. CONCLUSION: Patients with prior PCI who present with non-ST-segment elevation ACS have a lower mortality rate than those without prior PCI.     

Association of vascular compression in trigeminal neuralgia versus other “facial pain syndromes” by magnetic resonance imaging

Magnetic resonance imaging was performed in 13 patients with trigeminal neuralgia and 18 control patients with facial pain of other types. Among trigeminal neuralgia patients, eight (62%) had vessels seen abutting, or immediately adjacent to, the trigeminal nerve on the side of their symptoms. Only three control patients (17%) had such vessels. The proportion of patients having a trigeminal region vessel associated with their symptoms was significantly higher in patients with trigeminal neuralgia than in controls (p = 0.0086). These findings provide evidence supporting the theory that trigeminal neuralgia is associated with vascular compression of the fifth cranial nerve.     

医院内诺如病毒感染的三种病原学检测方法应用比较

目的找到一种简便易行的检测感染性腹泻粪便标本中诺如病毒的方法。方法用两种酶免疫吸附试剂盒检测北京地区婴幼儿腹泻和综合医院内成人感染性腹泻粪便标本中的诺如病毒,并用逆转录-聚合酶链反应(RT-PCR)作对照,评价这两种试剂盒。用两种试剂盒分别检测69份儿科病房标本和来自3家综合医院15份成人医院内感染性腹泻的粪便标本中诺如病毒;其中5份儿科病房和15份成人病房的粪便标本还同时进行了RT-PCR检测。结果84份粪便标本中,试剂盒甲的诺如病毒检出率为20.2%(17/84),试剂盒乙的诺如病毒检出率为36.9%(31/84);两种试剂盒的符合率为73.8%(62/84),但试剂盒乙的检出率显著高于试剂盒甲(P<0.01)。在应用了RT-PCR检测的20份标本中,阳性率为55.0%(11/20)。试剂盒甲与RT-PCR检测结果相比,检出率明显低于RT-PCR(P<0.05),试剂盒乙与RT-PCR检测结果相比,检出率差异无统计学意义(P>0.05)。3家综合医院的成人标本中,每家医院都有2份或2份以上送检标本诺如病毒检测阳性,结合临床诊断可判定为诺如病毒医院内感染暴发。结论酶免疫吸附方法检测诺如病毒感染简便易行、利于推广,试剂盒乙可以替代RT-PCR方法应用于临床。3家综合医院都存在诺如病毒医院内感染的暴发。     

Was bleibt von der Haut nach 2000 Jahren Moor?

BACKGROUND AND OBJECTIVE: Mummies have an important place in the study of archaeology and paleopathology because they are so well preserved. For the first time skin samples of six 2300-1600 year old bog bodies from North Germany were examined by histology, transmission electron microscopy and immunohistology. METHODS: For histology the samples were stained with H&E and van Gieson elastic stain. Fixation and embedding in epoxy followed for the transmission electron microscopy. Specific antibodies directed to type IV collagen and S-100 were used. RESULTS: Histologically it was possible to observe collagen bundles in the dermis, with a density similar to recently stained samples. Epidermis was not preserved. The electron microscopy showed collagen fibrils with a diameter of 45-110 nm and the characteristic axial periodicity. Throughout the dermis, a number of spores of bacteria with a diameter of 0.83 +/- 0.051 micron and an electron dense core were found. No activity against the used antibodies could be detected. CONCLUSIONS: Histology and electron microscopy demonstrate the excellent conservation of the dermal collagen in the bog. In contrast to ice mummies like "Otzi" and mummies from Egypt, no cellular elements could be found in the skin of bog bodies.